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Insomnia is common in the early stages of addiction treatment, but recent research at Caron Treatment Centers suggests that persistent and prolonged insomnia puts people at higher risk of relapse.
Caron has been in the forefront of using neuroimaging techniques such as Functional Near-Infrared Spectroscopy (fNIRS) to explore addiction’s impact on the brain. fNIRS uses infrared wavelengths of light to track oxygenated versus deoxygenated blood flow in the brain, enabling researchers to see what parts of the prefrontal cortex are activated as patients perform different tasks. This research has led to some startling findings.
For example, Caron conducted two pilot studies, each with 50 participants -- one cohort of 50 participants was in treatment for alcohol use disorder, while the other cohort of 50 were diagnosed with an opioid use disorder. In both cohorts, fNIRS tests conducted weeks into treatment were able to predict future relapses over 80 percent of the time. The research is still in its early stages, but an ability to reliably predict relapse would be an astounding leap forward, enabling us to move proactively in prevention.
One of the surprising findings during this research is that persistent insomnia was an independent risk factor for relapse. If someone was having difficulty sleeping, they were much more likely to relapse.
Good Sleep is Essential to Recovery
Insomnia is the inability to get qualitative sleep. Either people have difficulty falling asleep, or they wake up early and can’t get back to sleep. Insomnia is common in the early stages of recovery from addiction. The brain adapts to the effects of one’s drug of choice in the active addiction phase of the disease, needing time to “reset itself” in early recovery. Most people will readjust in a few weeks, but there are some that do not; they are at greater risk of relapsing.
Sleep is essential to our brains, and insomnia can have a broad range of effects in different areas of the brain. Sleep is particularly important in mood regulation. People who are chronically sleep-deprived tend to be short-tempered, dysregulated, or feel anxious.
It is this “mood dysregulation” that seems to affect relapse risk, because people try to medicate those dysregulated feelings away. ASAM defines addiction as a pathological pursuit of reward or relief. The pursuit of relief – from persistent insomnia -- leads to relapse. The relapse is driven less by a need for a reward than an attempt to relieve the symptoms they’re experiencing with insomnia.
Insomnia affects recovery in many other ways. Ability to concentrate is grossly disturbed with persistent insomnia, so people with insomnia find it difficult to do the work they need in addiction treatment. They end up not progressing like they should, because you need a certain amount of attention and concentration to progress adequately in treatment.
While persistent insomnia doesn’t affect a large percentage of the people we treat, for the patients that do go through it, there is a tremendous impact on them and their recovery.
Help for Those with Insomnia
We might once have thought that we could just allow nature to take its course, but, with insomnia emerging as a sign of a potential relapse, we can’t let people just “tough it out” because that might end up with a deleterious outcome. We are now taking a more proactive approach to dealing with insomnia during addiction treatment.
Obviously, the first thing that needs to be done is to instill good sleep hygiene. Things like:
• Not drinking caffeine or eating chocolate before you go to bed.
• Not exercising heavily before bedtime.
• Not using electronic devices right before bedtime.
• Sticking to a schedule for going to bed and waking up.
• Not lying in bed when it’s not time to sleep.
• Making sure your bedroom is dark, quiet, and comfortable.
If these strategies don’t work, then we step into other therapies. At Caron, we often use melatonin, which is a natural sleep aid. We might also consider a short term non-addictive pharmacological strategy, to restore natural sleep. Some anti-depressants have a sedating effect, so we might use a very low dose of Trazodone, Doxepin, or Remeron, much lower than their anti-depressant dosages. One thing we never use are benzodiazepines such as Xanax or non-benzodiazepine hypnotics such as Ambien, because they are addictive.
Caron is also initiating a research study on the use of a non-addictive sleep medicine called Suvorexant, (Belsomra), to see what benefits it might have on insomnia-triggered relapse. We will provide additional information on that research in a future post.
We all have nights when we find it difficult to fall asleep, but persistent insomnia is far more than just an occasional sleepless night. For those in recovery, persistent insomnia can be a warning sign of a higher risk of relapse. Sleep health is not a minor issue, and new research is helping us understand how important healthy sleep is to a healthy life.